Switching from Buproprion/quetiapine to an MAOI

[luckrules]

I brought up a TRD patient the other day that I was considering trying an MAOI on but have limited experience with the use of these agents. I was pleased with some of the discussion on this forum and found it helpful, but I have some additional questions I was hoping to get help with. Shout out to @Stagg737 @splik and @clausewitz2 for their help/previous contributions.

I know generally (from Stahl's, other sources) that you need a 5 half live/5-7 day wash out for most serotonergic agents prior to initiation MAO-I therapy. My patient is currently on buproprion 450 mg and seroquel 300 mg po qhs as well as klonopin BID. My reading of Stahl's suggests the klonopin can be continued, and he also mentions that atypical antipsychotics in general can be continued, at least for the "bridge."

My question is how long I should wait before starting an MAOI, and which drugs in particular I should stop prior to its use. I plan on stopping the bupropion, but since it has less serotonergic effects in general, do I need to do a washout? Secondly, while Stahl suggests atypical antipsychotics can be continued, I am concerned about quetiapine in particular due to its partial agonism at 5HT1a and other serotonergic effects.

Does anyone have any experience or can point me to a guideline that can direct switching from these agents to an MAOI? I am specifically considering parnate vs nardil. Any insight is appreciated. Thank you.

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[romanticscience]

This might be helpful: MAOIs: swapping and combining - Psychotropical

 

[luckrules]

This might be helpful: MAOIs: swapping and combining - Psychotropical

Great source, thanks. My reading of this is that it is probably safe to go ahead without a washout with quetiapine and buproprion. If anyone has any clinical experience supporting/refuting this, I appreciate it in advance.

Additionally, if anyone has a good patient resource to provide the patient on diet/drug interactions to be aware of, I would appreciate that too.

 

[sighchiatry]

Great source, thanks. My reading of this is that it is probably safe to go ahead without a washout with quetiapine and buproprion. If anyone has any clinical experience supporting/refuting this, I appreciate it in advance.

Additionally, if anyone has a good patient resource to provide the patient on diet/drug interactions to be aware of, I would appreciate that too.

Dr. Gillmans website has all the top info for MAOIs.

Here a short one about the diet:

https://psychotropical.com/wp-content/uploads/2020/03/9.1-MAOI-diet-short-2020_for-pdf_v.pdf

There are much more in depth articles on the website as well.

 

[birchswing]

Isn't the serotonergic effect of Seroquel stronger from its 5HT2A antagonism (potent) than its 5HT21 agonism (intermediate)? I was on a kick the other day on Wikipedia reading about every available 5HT2A antagonist (over 50!), which is the reason for my very narrow knowledge on that.

Klonopin is slightly serotonergic.

<------Not doctor.

 

[clausewitz2]

Isn't the serotonergic effect of Seroquel stronger from its 5HT2A antagonism (potent) than its 5HT21 agonism (intermediate)? I was on a kick the other day on Wikipedia reading about every available 5HT2A antagonist (over 50!), which is the reason for my very narrow knowledge on that.

Klonopin is slightly serotonergic.

<------Not doctor.

Neither are SRIs, so neither of them matter in terms of interactions with MAOIs. That's really the important bit.

 

[deleted1100659]

I brought up a TRD patient the other day that I was considering trying an MAOI on but have limited experience with the use of these agents. I was pleased with some of the discussion on this forum and found it helpful, but I have some additional questions I was hoping to get help with. Shout out to @Stagg737 @splik and @clausewitz2 for their help/previous contributions.

I know generally (from Stahl's, other sources) that you need a 5 half live/5-7 day wash out for most serotonergic agents prior to initiation MAO-I therapy. My patient is currently on buproprion 450 mg and seroquel 300 mg po qhs as well as klonopin BID. My reading of Stahl's suggests the klonopin can be continued, and he also mentions that atypical antipsychotics in general can be continued, at least for the "bridge."

My question is how long I should wait before starting an MAOI, and which drugs in particular I should stop prior to its use. I plan on stopping the bupropion, but since it has less serotonergic effects in general, do I need to do a washout? Secondly, while Stahl suggests atypical antipsychotics can be continued, I am concerned about quetiapine in particular due to its partial agonism at 5HT1a and other serotonergic effects.

Does anyone have any experience or can point me to a guideline that can direct switching from these agents to an MAOI? I am specifically considering parnate vs nardil. Any insight is appreciated. Thank you.

One thing no one has mentioned here. What are you calling TRD? What are they reporting their PHQ 9 as? What was it in the past? What meds have they failed? Wellbutrin and seroquel is such an odd combination, to me. Make sure you have a really thorough med history. Also identify current stressors. Someone with 10000 current stressors, one helpful solution is identifying ways to cope with them/therapy/or even seeing if any have any obvious fixes that people are missing.

Also , selegine patch has fewer interactions, if youre set on an MAOi.

 

[clausewitz2]

Also , selegine patch has fewer interactions, if youre set on an MAOi.

Selegine patch does end up having the same drawbacks as a more traditional MAOI in high doses, and has the drawback of being a bit pricey at that point. Perhaps unsurprisingly if we believe MOA has anything to do with therapeutic efficacy, you will find a lot of clinical experience suggesting that it is also only as helpful as traditional MAOIs at those higher doses.

If insurance doesn't want to play ball, Emsam is going to cost like $1800 a month for a month's supply of 6 mg patches. A month's supply of Parnate out of pocket is still under $200.

 

[NickNaylor]

We will occasionally start MAOIs in patients taking antipsychotics (most commonly quetiapine and olanzapine). Our general practice has been not to washout from the antipsychotics, and we will often use them concomitantly with MAOIs. Haven't had any issues with this strategy in the small number of patients our group has done this on.

Agree with the comments about selegiline - I use MAOIs not infrequently but almost never use selegilene, and certainly not as a first-line choice. The patch is theoretically nice, but it is often prohibitively expensive and, apart from the theoretical benefit of not having to follow the diet at the lowest dose (which is a joke, because rarely is the lowest dose going to be efficacious in my experience), I see no real advantage with it clinically. Phenelzine and tranylcypromine are perfectly fine in most cases and generally cheaper than the selegilene patch.

 

[deleted1100659]

We will occasionally start MAOIs in patients taking antipsychotics (most commonly quetiapine and olanzapine). Our general practice has been not to washout from the antipsychotics, and we will often use them concomitantly with MAOIs. Haven't had any issues with this strategy in the small number of patients our group has done this on.

Agree with the comments about selegiline - I use MAOIs not infrequently but almost never use selegilene, and certainly not as a first-line choice. The patch is theoretically nice, but it is often prohibitively expensive and, apart from the theoretical benefit of not having to follow the diet at the lowest dose (which is a joke, because rarely is the lowest dose going to be efficacious in my experience), I see no real advantage with it clinically. Phenelzine and tranylcypromine are perfectly fine in most cases and generally cheaper than the selegilene patch.

Tbh, I rarely use MAOis, but that is because of where i practice, my patient population tends to be on the more acute side so to speak, and where some people are on more medications than their age. So i get nervous trusting the patient to follow specific instructions in regards to the class of medications.

This may sound obvious, but I think therapy can be a powerful adjunct, and often beats contributing to a complicated med list. Obviously not an option for all people, but I would really want the patient who is not benefiting from meds to the extent they want, to get in with a good therapist and give it a shot.

But again, usually with TRD I find a lot of patients have specific reasons they have TRD. Not everyone, but a good number

 

[clausewitz2]

Tbh, I rarely use MAOis, but that is because of where i practice, my patient population tends to be on the more acute side so to speak, and where some people are on more medications than their age. So i get nervous trusting the patient to follow specific instructions in regards to the class of medications.

This may sound obvious, but I think therapy can be a powerful adjunct, and often beats contributing to a complicated med list. Obviously not an option for all people, but I would really want the patient who is not benefiting from meds to the extent they want, to get in with a good therapist and give it a shot.

But again, usually with TRD I find a lot of patients have specific reasons they have TRD. Not everyone, but a good number

If someone is older and on beaucoup medications, MAOIs are actually ideal. Beyond a handful of SRIs and some opioids, drug-drug interactions are nonexistent.

But yes, of course, one should be pursuing therapy as well. I can say confidently that anyone I have prescribed an MAOI to is also seeing a therapist and had been for some time.